ER tranquillisation

A single Intramuscular administration of haloperidol (10mg) plus promethazine (50 mg)is the ideal combination for sedating and tranquilizing violent psychotic patients.
In the recent BMJ two randomised controlled trials assess the effectiveness of two antipsychotics: haloperidol and olanzapine.

One trial in Brasil (n= 311) compared 5-10 mg haloperidol intramuscular to the combination of haloperidol (5-10 mg) plus up to 50 mg of promethazine. After 20 minutes significant more patients on the combination were tranquil or asleep compared to haloperidol alone. Moreover, 10 cases of acute dystonia occurred in the haloperidol group. None in the combination group had this side-effect.

One trial in India compared intramuscular olanzapine (10 mg) with haloperidol (10 mg) plus promethazine. This latter combination not only resulted in rapid and effective tranquilisation but also resulted in fewer additional medical interventions within four hours of intervention. No patient experienced dystonia.

intramuscular olanzapine is as good as intramuscular haloperidol plus promethazine if the doctor is willing to take a 20% chance of being called back an hour later to give another dose.

Conclusions about rapid tranquillisation.
Rapid tranquillisation can prevent patients from longer periods of aggression than necessary. These measures can also prevent distressing situations.

From the patient’s perspective, being asleep is also less traumatic than being physically restrained. These considerations, and the lower cost, favour the combination of haloperidol-promethazine over olanzapine for the emergency management of violent patients in the developing world.

This last quote may also be applicable to short staffed ER departments in the Western countries?

Rapid Tranquillisation is not to be confused with rapid neuroleptization. Used in the 70’s and 80’s of the previous century. This method is now considered obsolete.

literature on the rapid neuroleptization (titration) method with I.M. haloperidol. Most of the approximately 650 predominantly schizophrenic and manic patients represented in the studies calmed down rapidly on medication, and some demonstrated an early reduction in core psychotic symptoms. The initial doses varied widely, ranging from 1 to 30 mg, with a maximum total daily dosage of 100 mg.

There is no evidence that large loading doses of neuroleptics speed or enhance treatment response.

The aim of rapid neuroleptization was reduction of symptoms not tranquillisation which aim is to sedate a violent psychotic patient.

Articles discussed:
Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine

Gisele Huf, associate professor1, E S F Coutinho, professor2, C E Adams, associate professor3, for the TREC Collaborative Group
BMJ, doi:10.1136/bmj.39339.448819.AE (published 22 October 2007)

Rapid tranquillisation in psychiatric emergency settings in India: pragmatic randomised controlled trial of intramuscular olanzapine versus intramuscular haloperidol plus promethazine

Nirmal S Raveendran, lecturer1, Prathap Tharyan, professor2, Jacob Alexander, lecturer1, Clive Elliot Adams, associate professor3, for the TREC-India II Collaborative Group
BMJ, doi:10.1136/bmj.39341.608519.BE (published 22 October 2007)